Cherokee Nation Pharmacy Director Jeff Sanders and Pharmacist Amy Christie point out features of the tribe’s new central pharmacy’s automation system. Located at Three Rivers Health Center in Muskogee, Okla., the system will be used to fill prescriptions for pick-up at all CN medical facilities. COURTESY PHOTO
CN to implement automated central pharmacy
MUSKOGEE, Okla. – Patients of the Cherokee Nation’s health system will soon enjoy faster, more efficient pharmacy services.
A new central pharmacy located at Three Rivers Health Center in Muskogee features an automation system that will fill prescriptions for pick-up at all CN medical facilities and be used for mail order prescription services.
Jeff Sanders, the tribal health system’s pharmacy director, said the central pharmacy’s automated system is efficient and capable of handling the large volume of prescriptions it’s expected to see.
“With this system, we will be able to fill 10,000 prescriptions per eight hour shift,” said Sanders. “It will open with a staff of 11 including four pharmacists, five techs and two clerks.”
Sanders said that most traditional pharmacies fill 100 to 180 prescriptions per pharmacist in a shift of eight hours. In 2010, CN pharmacies filled almost 1.25 million prescriptions.
With its conveyor belts and quality check stations, the automated system has the appearance of a manufacturer’s assembly line. The system is software driven. It sorts, measures and packages prescriptions for distribution. The pharmacy staff will oversee the operation and be on hand to assure the quality of the prescriptions the system fills.
Sanders said the transition to an automated central pharmacy will be seamless for patients and that there will be no interruption in their prescription drug supply. He also said he encourages patients to take advantage of the mail order prescription service available to them.
“We want our people to sign up for mail order prescriptions,” he said. “It cuts down on lines at the clinics, and that makes patients a lot happier.”
The new pharmacy service is scheduled to be in full use by all CN health centers by June 30.
TAHLEQUAH, Okla. – The Cherokee Nation is blazing a path in hepatitis C treatment with a project that is curing Cherokees infected with the disease. At the project’s center is Dr. Jorge Mera, infectious diseases director, who in October founded a hepatitis C elimination project.
The CN has the first health organization in the country to start such a program, he said.
“But before the elimination program we started addressing the problem in 2012 through September of 2015 with increased screenings other patient care,” Mera said.
The project has screened 12,000 Cherokee patients for hepatitis C, and among those testing positive, more than 300 have been treated and are considered cured of the infection that causes liver disease, officials said.
That project earned Mera the distinction of being honored in May at the White House ceremony on National Hepatitis Testing Day.
“The award is a wonderful recognition from the White House to all the Cherokee Nation providers, health professionals and administration for making this program a success in changing lives and combating hepatitis C,” Mera said after the ceremony. “We have a lot of work ahead, but I think we have made the invisible epidemic, now visible.”
An estimated 3.5 million people have hepatitis C, according to the U.S. Health and Human Services. According to a CN press release, the number of hepatitis C-related deaths reached an all-time high of 19,659.
However, Mera said, patients are now being treated with Food and Drug Administration-approved hepatitis C virus antivirals.
“The cost of a treatment varies, but a treatment may cost from $52,000 to over $100,000 depending on the combination of drugs used,” Mera said. “Of the patients who have completed treatment we have a cure rate that is around 90 percent.”
The program’s protocol follows the American Association for the Study of Liver Disease and Extended Community Health Outcomes recommendations.
“No patients have died while receiving antiviral drugs but several patients have died of end stage liver disease either before they received treatment or after they completed treatment,” Mera said.
No hepatitis C vaccine exists, but there is ongoing research to develop one, he said.
“It is the No. 1 cause of mortality of the reportable infectious diseases in the United States,” Mera said. “It causes more deaths than the other 59 diseases combined.”
Mera said in the United States more that 70 percent of the infected are in the Baby Boomer Generation, people born between 1945-65.
“In Cherokee Nation the patients we are detecting now have an average age of 44,” Mera said. “Around 50 percent of our patients are in the Baby Boomer age group but the other half is younger.”
Within the elimination program, there are research studies regarding transmission risk factors in the CN population, Mera said.
The highest risk of contracting hepatitis C is probably in people who inject drugs by sharing contaminated needles, syringes or paraphernalia used during the injection process and having unprotected sex with an infected partner, he said.
Treatment of patients with substance abuse disorders is also important because this will decrease their chances of using drugs. So having behavioral health, rehab services and opioid substitution programs are also important parts of prevention.
“Also, tattooing is a possible risk factor so only getting tattoos done by professionals who are licensed,” Mera said.
Treatment of infected patients also is a form of prevention because once a patient is cured he or she cannot transmit the infection, he said.
“Most patients are asymptomatic,” Mera said. “When symptoms appear it usually is a manifestation of advanced liver disease or liver cancer.”
Screening is the key to early detection of the disease, he said.
Eighty-five percent of patients will develop a chronic infection and between 20 percent and 30 percent will develop cirrhosis of the liver, he said.
<strong>Facts About Hepatitis C</strong>
• Hepatitis C can begin as acute infections, but in some people, the virus remains in the body, resulting in chronic disease and long-term liver problems.
• Hepatitis C ranges in severity from a mild illness lasting a few weeks to a serious, lifelong illness that attacks the liver. It is spread primarily through contact with the blood of an infected person. About 75 percent to 80 percent of people infected with the virus develop chronic infection, a long-term illness when the virus remains in a person’s body. It can lead to serious liver problems, including cirrhosis or scarring of the liver or liver cancer.
OKLAHOMA CITY (AP) – The Cherokee Nation has been awarded a $1 million grant as part of an effort to get more children enrolled in federal welfare programs for which they are eligible, federal officials announced on June 13.
The Center for Medicare and Medicaid Services announced the Tahlequah-based tribe is one of 38 recipients from 27 states to receive part of the $32 million in awards that are called Connecting Kids to Coverage grants. The money is aimed at enrolling eligible children in Medicaid and the Children’s Health Insurance Program, or CHIP, which is another program that provides health coverage to children.
“Unfortunately, the Cherokee Nation has 22 percent of their (eligible) kids who have not signed up,” Principal Chief Bill John Baker said. “This million-dollar grant gives us the opportunity to do more outreach, to get in the communities, to PTA meetings, school functions, maybe even some billboard advertising, things like that to educate and make more of our citizens aware that this health care is available to the kids.
Baker said because CN citizens who live within the tribe’s boundaries already receive free health care at tribal clinics, they may not be aware that they also qualify for federal programs like Medicaid.
The CN was the only Oklahoma recipient in the latest round of awards, which specifically target vulnerable populations, including teenagers, children in rural communities and Hispanic and American Indian children, said Victoria Wachino, director of CMS’ Center for Medicaid and CHIP Services.
“Today’s announcement means more children will have access to coverage early in their lives which will help them grow into healthy adults, succeed in school and reduce financial burdens on their families,” Wachino said.
Figures released on June 13 by CMS show more than 710,000 Oklahoma children enrolled in Medicaid and CHIP programs in 2015, an increase of nearly 2 percent from 2014, but still below the national average of 2.5 percent.
“Since the passage of the Affordable Care Act, the rate of uninsurance for children has declined to its lowest levels on record,” U.S. Secretary of Health and Human Services said. “Fewer than 1 in 20 children are now uninsured.”
WASHINGTON – A Cherokee Nation physician was honored at the White House on May 19 for the tribe’s commitment to testing and treating patients for hepatitis C, which has led to more patients being cured of hepatitis C and living longer lives.
Acting Assistant Secretary of Health Karen B. DeSalvo presented Dr. Jorge Mera, CN infectious diseases director, his award during a White House ceremony in observance of National Hepatitis Testing Day.
“The award is a wonderful recognition from the White House to all the Cherokee Nation providers, health professionals and administration for making this program a success in changing lives and combating hepatitis C,” Mera said. “In the last couple of years we have tested thousands of patients and cured hundreds who suffer from the hepatitis C virus. We have a lot of work ahead, but I think we have made the invisible epidemic, now visible.”
The CN, thanks in large part to Mera, began a hepatitis C elimination project in 2015. The tribe executed plans developed by the U.S. Centers for Disease Control and Prevention. To date, the CN has screened more than 12,000 Native American patients for hepatitis C. Among those testing positive, more than 300 have been treated and are considered cured of the infection that causes liver disease.
“At Cherokee Nation we are diligently addressing hepatitis C infection within our tribal population. We are able to do that because of the ongoing partnership with the CDC, and I thank Dr. Mera and his team for their work. It is a pioneering effort and I am proud we are making great strides,” Principal Chief Bill John Baker said. “Indian people face a huge disparity in the rate of contracting hepatitis C in America, but through our efforts we are educating our citizens and systematically fighting, and even curing, hepatitis C. Hopefully, these best practices will soon be replicated across Indian Country.”
An estimated 850,000 Americans have hepatitis B and 3.5 million have hepatitis C, and fewer than half are aware of their infections, according to the U.S. Department of Health and Human Services.
Since 2012, deaths associated with hepatitis C outpaced deaths due to all 60 other infectious diseases, and in 2014, the number of hepatitis C-related deaths reached an all-time high of 19,659.
National Viral Hepatitis Testing Day is an annual CDC-sponsored observance. This year, the HHS collaborated with the White House Office of National AIDS Policy and Office of National Drug Control Policy for the Hepatitis Testing Day event to highlight the impact of viral hepatitis in the United States.
It is the first year the HHS presented awards to organizations testing for hepatitis. Other health organizations recognized were from Hawaii, Rhode Island, New York, New Jersey, Washington, D.C., San Diego, Dallas and Wyoming.
“Increasing testing for hepatitis B and C is a critical part of ensuring good health for all Americans,” DeSalvo said. “With coordinated efforts by diverse partners like those being recognized…we can reduce deaths and disparities in hB and C and improve the lives of people living with chronic viral hepatitis.”
KENWOOD, Okla. – The Cherokee Nation’s Trust Land Kenwood Units have plants such as Trillium, which contain medicinal properties, and Buckbrush, which can be used for making baskets. Pat Gwin, administrative liaison, said the approximately 160-acre Delaware County tract, which is not accessible to the general public, is home to culturally significant and medicinal plants.
“We might have hit five acres of it and we saw this list of what is twentyish really important plants, so that’s a neat tract,” he said.
While on the tract, Gwin spotted Trillium, a short-lived medicinal plant.
“A lot of Cherokee medicinal, cultural food plants only grow in like a two-to-four-week window here in the spring, and Trillium is one of those. It’s a medicinal plant and there are years when it is very prevalent and there are years when you can’t find it very often,” he said.
Gwin declined to comment on the plant’s medicinal purposes for safety reasons. He suggested people wanting to use medicinal plants seek a Cherokee medicine person. He did the same for May Apple, which he also found.
“May Apple was another one of those medicinal plants, cultural-use plants. The strange thing about the May Apple is that it was used for a lot of cures that western medicine hasn’t really done a lot of research on or is just now starting to do some research on. If you go to other parts of the world it’s been used for a lot of the same medicinal uses that the tribe has for centuries,” he said.
He said another plant he saw was Sassafras, which was used as a blood thinner.
“Sassafras, its medicinal qualities have been made known for a longtime. It’s used as a blood thinner,” he said. “Today, it’s got some controversy surrounding it because one of the main ingredients, the Safrole Oil, is a carcinogen, so there’s a lot of warning out there for people that do partake of it do so in moderation. It has three distinct leaves. It has the sock that’s the round leaf and then it has the mitten and then it has the glove. No other tree has that so I think that’s pretty cool.”
Other notable plants found were Wild Ginger, which Gwin said is used as a food additive and for medical purposes; Solomon Seal, which he said “highly skilled Cherokee healers” would have used; and Green Dragon, which Gwin said is kin to Jack-in-the-Pulpit and used for medicinal purposes.
Gwin also found Sochan, a plant offered through the tribe’s Seed Bank Program.
“(It’s) one of the traditional Cherokee greens that’s eaten in the spring,” he said. “You might say it’s somewhat a kin to Watercress, but most people don’t know that Watercress probably isn’t even from North America.”
He said another plant in the area that is culturally important is Buckbrush.
“Buckbrush would have been the one they (Cherokee baskets weavers) used,” he said. “A lot more difficult than Honeysuckle because it just doesn’t grow as long.”
Gwin said most of these plants would be found in “low-lying wetland areas.”
“One of the things that when you look for areas that are going have a lot of Cherokee plants you have to think at a couple of things. Cherokees always needed water,” he said. “A significant number of those plants would be found in those low-lying wetland areas, which environmentally, those are sensitive areas.”
Gwin said it’s important for Cherokees to know about plants that are important to their people.
“There were a couple of things that our ancestors told us that we had to retain in order to be Cherokee. Obviously one of them was language. Obviously one of them was the ability to grow our own food. The ability to utilize and respect plants was another one of those things,” he said. “The Cherokee homeland is a very diverse plant environment as is northeastern Oklahoma. I always found it interesting. The relocation could have been far worse than what it was, but they stopped here in northeastern Oklahoma where we may not have all the same plants as we did back there but, for example Jack-in-the-Pulpit, very cultural Cherokee plant, very prevalent back East, not so much here but we have the Green Dragon, which…it’s so close in relation.”
He said he plants are some of the things that helped Cherokees thrive in the modern CN.
“Even now we might not have the exact same plants. We have very, very close cousins, kins to them. That’s one of the things that I always thought allowed us to, once we got here, build up the tribe as quickly as we did,” he said. “I’m not sure any other population on the planet would have been able to survive that but that was one of the things that we were able to do, and I truly think the plants was one of the reasons for that.”
For information about Cherokee-important plants or to tour the tribe’s Garden and Native Plant Site, email <a href="mailto: firstname.lastname@example.org">email@example.com</a>.
TAHLEQUAH, Okla. – With international health officials sounding the alarm, Cherokee Nation Public Health officials are preparing for the Zika virus.
Earlier this year, the CN was one of three tribes to participate in the Centers for Disease Control’s Zika summit in Atlanta.
Lisa Pivec, Public Health senior director, said while the CN’s jurisdiction is considered to be a low risk for an outbreak, plans and partnerships with the Oklahoma Department of Health and the CDC are in place as a proactive measure.
“The most important thing for us right now is getting a process in place,” she said. “The CDC has been great about helping us with that. We’ve seen what they’ve done with other infectious diseases, and they’re great about helping us get that done at the local level.”
For now that process involves keeping current information available to the public through www.cherokeepublichealth.org and maintaining regular contact among epidemiologists, communications professionals and environmental health specialists with all three entities.
As part of that partnership, any testing for the virus conducted at the tribe’s facilities is at no cost to the CN. Samples taken for testing are sent to the state health department’s offices in Oklahoma City and to the CDC in Atlanta where the actual test will be conducted.
So far, no tests have been submitted from a CN health facility, but Dr. David Gahn, Public Health medical director, said the tribe would be immediately notified if that changes.
According to the Oklahoma Department of Health, as of May 5, four cases of Zika had been reported statewide. All four were caused by travel to one of the more than 40 countries with a reported case of the virus.
The most common symptoms are fever, rash, joint pain, muscle pain, headaches and conjunctivitis. However, with the incubation period estimated at up to seven days, only 20 percent to 25 percent of those infected with the virus show any symptoms. No vaccine is available.
The people highest at risk of contracting the virus are men and women who have traveled to one of the countries or U.S. territories on the CDC’s advisory list. Pregnant women are considered particularly vulnerable due to the virus’ link to birth defects, including microcephaly, stunted fetal growth, vision problems and hearing problems.
“Most people who get Zika don’t really get ill,” Gahn said. “Among those who do, it’s very rare for even children to need hospitalization.”
The virus is also linked to an increased risk for Guillian-Barre syndrome, a disorder in which the body’s immune system attacks part of the peripheral nervous system. However, the CDC and other epidemiologists have not determined what causes the connection or which populations are more likely to be at risk of developing Guillian-Barre as a side effect of the Zika virus.
“We don’t know what’s the risk yet, as in how many people who are infected with Zika will get and which ones,” Gahn said. “We just don’t know the risk factors yet. Does it go after older people? Men? Women? Teenagers?”
Although the virus can also be spread through unprotected sexual contact with an infected man, many of the preventative measures being touted to the public are aimed at its other means of transmission: mosquitoes.
As a mosquito-borne virus, many measures used to curb the spread of the West Nile virus are equally effective against Zika. Along with the use of an EPA-registered insect repellant, wear long-sleeved shirts and long pants whenever possible and citizens are encouraged to not leave doors and windows propped open unless covered with a properly maintained screen.
Additionally, mosquitoes can be kept at bay by not leaving standing water around the home. Birdbaths, rainwater collectors, kiddie pools, trash cans and other containers that could potentially hold water should be emptied out at least weekly, as mosquitoes lay eggs in standing water. Cracks or gaps in septic tanks should be patched and any exposed vents or plumbing pipes should be covered.
More preventative measures are available at <a href="http://www.cdc.gov/zika/prevention/controlling-mosquitoes-at-home.html" target="_blank">http://www.cdc.gov/zika/prevention/controlling-mosquitoes-at-home.html</a>.
The two main species of mosquito that carry Zika, Aedes aegypti and Aedes albopictus, are generally not found in Oklahoma. However, that has not deterred officials with tribe’s health department from encouraging CN citizens from taking a proactive approach to prevent Oklahoma’s first mosquito-borne case from arising in the jurisdiction.
“For us, it’s about putting together the best plans we can based on risk levels and being as responsive as possible without creating worry or concerns that are not warranted,” Pivec said. “We know that we’re prepared if the situation changes.”
TAHLEQUAH, Okla. – At the May 16 Health Committee meeting, Tribal Councilors questioned Health Services Director Connie Davis and Brett Hayes, who oversees the tribe’s contract health department, about contract health referral reductions for the rest of the fiscal year and the department’s shortfalls.
According to an emailed letter from Health Services Executive Medical Director Dr. Roger Montgomery to Davis, who then forwarded it to Tribal Councilors, each year the tribe overspends its contract health budget and he recommends “people cut back on the referrals they write.”
“People don’t really cut back all that much and administration makes up the difference with collections from the clinics, etc., so we don’t end up having to push the issue,” Montgomery states. “This year, with the implementation of a new electronic health record leading to reduced clinic schedules, and the addition of approximately 10,000 patient visits this year, there are no additional collections to pad Contract Health’s overruns.”
Montgomery states that in the first seven months of FY 2016 the tribe spent $25 million of its $35 million contract health budget.
“That leaves $10 million available for the last five months of the fiscal year and no expected increased collections to cover the remainder. If payments for transfers out continue at the same pace of about $200,000 per month, it actually leaves $9 million for everything else,” he writes.
At the meeting, Davis said She said the lack of in-house procedures because of referrals has caused contract health spending to get out of control.
“So we’ve asked our docs to do a better job managing patients within our own health centers and not sending them out for things like knee injections, shoulder injections or casting,” she said.
She added that the health system had grown by about 10 percent annually since she’s led Health Services and that has impacted spending.
“We’ve budgeted a flat budget with contract health all these years, and so it’s obvious that there’s at some point that we’re going to have to slow some of the (referrals),” she said.
Many referrals are approved now that historically hadn’t always been approved, including pain management and orthopedic procedures, Hayes said.
Montgomery states that to solve overspending for the rest of FY 2016 requires referral reductions.
“Because of our three chance appeals process, the only real way to ensure not spending money on a referral is to not write the referral at all. In our case, this means reducing the number of referrals written by as much as 50 percent. Contract Health money is and was traditionally earmarked only for urgent and emergent care. It was never intended for elective care,” he states. “It was never intended for routine follow-ups in patients not having further issues. It was never intended for things we could do ourselves, even if it meant waiting a bit for the care. We added money in the past in programs such as Back to Work to help pay for some of the elective procedures. However, when that money was no longer available, we never dropped those new service lines.”
<strong>Referrals that could be reduced included in Montgomery’s statement were:</strong>
• Dizziness workups that were instigated by a vendor apart from the original reason for the referral,
• Prophylactic mastectomy that could be performed at Hastings,
• Circumcision revisions for cosmetic purposes,
• Dermatology: simple excisions, punch biopsies, actinic and seborrheic keratosis treatments and skin tag removals,
• Simple wound care,
• Elective gallbladders, hernias, hysterectomies, etc., that could be performed at Hastings,
• Cardiac clearance by cardiologists that can be done in-house,
• Varicose veins,
• Long-term follow-ups for benign or distant conditions,
• Elective orthopedics-joint replacements,
• Elective repairs,
• Injections at outside vendors,
• Non-elective orthopedics-simple casting,
• PET scans that don’t change treatment,
• Cataracts before Medicare kicks in, and
• Allergy testing and reduction mammoplasty.
Not all non-urgent, non-emergency procedures are included in the list. The list was in reference to one day’s referrals, according to Montgomery’s statement.
Montgomery also states that providers would have to “police themselves” when writing referrals.
“If your case manager is writing all your referrals for you without any real discussion, you will need to halt this practice…Another option is to advocate to your patients the importance of signing up for available resources, such as insurance from the Affordable Care Act, Medicaid, and Medicare Part B,” Montgomery states. “We can pay for 5 insured referrals for every one uninsured referral. This also brings money into your individual clinics, which allows you to pay for raises, new providers, and creates the cushion that Contract Health used to use when there are overruns. Explain to your patients that signing up for these things are a huge help to Cherokee Nation Health. Ask them if they can afford to and are willing to help.”
Montgomery states that if these options were unsuccessful each clinic would be given a budget to work from and be required to review their referrals daily and work within that budget.
“If we still aren’t getting under budget, more drastic action would need to be taken,” he states.